1. No category

Management of Constipation in Children and Adolescents With Autism
Spectrum Disorders
Glenn T. Furuta, Kent Williams, Koorosh Kooros, Ajay Kaul, Rebecca Panzer, Daniel
L. Coury and George Fuchs
Pediatrics 2012;130;S98
DOI: 10.1542/peds.2012-0900H
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/130/Supplement_2/S98.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
Management of Constipation in Children and
Adolescents With Autism Spectrum Disorders
abstract
OBJECTIVES: To develop a practical, readily applied algorithm for primary health care providers to identify, evaluate, and manage constipation in children with autism spectrum disorders (ASDs).
METHODS: The Gastroenterology Committee of the Autism Speaks Autism Treatment Network (ATN), a multisite consortium of centers dedicated to improving standards of medical care for children with ASDs,
guided the development of the constipation algorithm through expert
opinion and literature review. The algorithm was finalized based on
results of field testing by nongastrointestinal, ATN autism medical specialists at 4 ATN sites. A systematic review and grading of the literature
pertaining to constipation and children with ASDs was also performed.
RESULTS: Consensus among the ATN Gastroenterology Committee identified that in children with ASDs, (1) subtle or atypical symptoms might
indicate the presence of constipation; (2) screening, identification, and
treatment through a deliberate approach for underlying causes of constipation is appropriate; (3) diagnostic-therapeutic intervention can be
provided when constipation is documented; and (4) careful follow-up
after any intervention be performed to evaluate effectiveness and
tolerance of the therapy. Literature review revealed limited evidence
for the clinical evaluation or treatment strategies of children with
ASD and constipation.
CONCLUSIONS: Constipation and its underlying etiology have the potential to be effectively identified and managed using a systematic approach. Lack of evidence on this topic in the literature emphasizes the
need for research. Pediatrics 2012;130:S98–S105
AUTHORS: Glenn T. Furuta, MD,a Kent Williams, MD,b
Koorosh Kooros, MD,c Ajay Kaul, MD,d Rebecca Panzer, MA,
RD, LD,e Daniel L. Coury, MD,f and George Fuchs, MDg
aDigestive Health Institute, Section of Pediatric Gastroenterology,
Hepatology and Nutrition, Children’s Hospital Colorado, University
of Colorado Denver School of Medicine, Aurora, Colorado;
bPediatrics, Division of Gastroenterology, Vanderbilt University
Medical Center, Nashville, Tennessee; cChildren’s Medical Center,
Dallas, University of Texas Southwestern Medical Center, Dallas,
Texas; dCincinnati Children’s Hospital Medical Center, Cincinnati,
Ohio; eCenter for Child and Adolescent Health Policy,
Massachusetts General Hospital for Children, Boston,
Massachusetts; fNationwide Children’s Hospital, Columbus, Ohio;
and gPediatric Gastroenterology, Hepatology, and Nutrition,
University of Arkansas for Medical Sciences and Arkansas
Children’s Hospital, Little Rock, Arkansas
KEY WORDS
autism, constipation, gastrointestinal disease
ABBREVIATIONS
ASD—autism spectrum disorder
ATN—Autism Treatment Network
GI—gastrointestinal
NASPGHAN—North American Society of Pediatric Gastroenterology, Hepatology and Nutrition
This manuscript has been read and approved by all authors.
This paper is unique and not under consideration by any other
publication and has not been published elsewhere. The
statements, findings, conclusions, and recommendation are
those of the author(s) and do not necessarily reflect the view of
MCHB, HRSA, or the U.S. Department of Health and Human
Services.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0900H
doi:10.1542/peds.2012-0900H
Accepted for publication Aug 8, 2012
Address correspondence to George Fuchs, MD, Arkansas
Children’s Hospital, One Children’s Way, Slot #512–7, Little Rock,
AR 72202. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
S98
FURUTA et al
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
SUPPLEMENT ARTICLE
Approximately 1 in 110 children fulfills
the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, diagnostic criteria for autism spectrum
disorders (ASDs): delayed or abnormal
social interaction, language as used in
social communication, and/or restricted
repetitive and stereotyped patterns of
behavior, interests, and activities.1,2 Over
the past quarter century there has been
an increased recognition of medical
comorbidities among children and
adolescents with ASDs, including unresolved and troubling gastrointestinal
(GI) concerns, such as diarrhea, gastroesophageal reflux–like symptoms, and
constipation, among others. GI symptoms
in children with ASD can be atypical and
manifest merely as a change in behavior,
thus presenting a significant challenge to
both parents and health care providers.3
Within this context, recognition and
treatment of these disorders in children
with ASDs are generally accepted to be
relatively understudied and ill defined.3
A previous report provided review of the
literature and consensus recommendations related to children with ASDs suspected of having a GI disorder, including
constipation.3 In addition, a comprehensive, evidence-based evaluation and
treatment algorithm for children aged 1
year and older with constipation was
developed by the Constipation Guideline Committee of the North American
Society of Pediatric Gastroenterology,
Hepatology and Nutrition (NASPGHAN).4
Although these documents are of significant importance, the previous reports do not provide a clinical pathway
for the treatment of constipation in ASD
or other neurodevelopment abnormalities. Additionally, the usefulness of the
NASPGHAN guideline in children with
ASD has not been evaluated.
The Autism Treatment Network (ATN)
was founded in 2005 with a goal to increase understanding and improve
care of children with ASDs. With the
marked increase in the incidence of
ASDs combined with lack of published
data on the management of GI disorders
in this subset of children, the need to
develop guidance for the primary care
practitioner has become even more
pressing. In the absence of relevant
data to develop evidence-based guidelines, it was determined that expert
opinion would be a helpful initial endeavor.
In response to this concern, the ATN
convened a committee of pediatric gastroenterologists and developmental pediatricians to develop evaluation and
management recommendations for
children with ASD and constipation.
Given that GI disorders are a major
comorbidity of ASD, the ATN GI committee
identified recognition, accurate diagnosis, and management of constipation
as a priority issue for parents of children
with ASDs and challenge to health care
providers.3 To prospectively study GI
problems in children with ASDs, the ATN
field tested a symptom questionnaire
that identified constipation as a major
problem.
METHODS
The ATN Gastroenterology Committee,
consisting of pediatric GI specialists
representing 14 sites as well as 2 developmental pediatrician representatives, gathered to address the challenge
of constipation in children with ASD.
Because of a paucity of data focusing on constipation in children with
ASD or with other neurodevelopmental
disorders, the ATN Gastroenterology
Committee used the NASPGHAN evidencebased guideline and algorithm for
constipation as an initial template.4 The
algorithm was modified to meet the
needs of clinicians serving children with
autism. In addition to development of an
ASD-specific algorithm and accompanying text, a complementary “checklist”
was developed as a practical tool. A
checklist, unlike the more comprehensive algorithm and text, was designed
specifically for practicality and application during clinic visits with the child
with ASD.
Algorithm Development
The adaptation of the NASPGHAN guidelines for this algorithm was completed in
2 stages. First, the ATN Gastroenterology
Committee members modified the
original guidelines by consensus, expert
opinion through a series of teleconferences, and face-to-face meetings.
The draft documents were reviewed by
ATN developmental pediatricians and
subsequently revised. Second, the ATN
selected 4 pilot sites (University of
Arkansas for Medical Sciences and
Arkansas Children’s Hospital, Cincinnati
Children’s Hospital Medical Center, University of Colorado Denver School of
Medicine, and the University of Rochester Medical Center) consisting of autism
health care providers (not GI specialists) who tested the feasibility of the
algorithm over a 6-month period in an
effort to identify points of concern; the
intent was not to validate the algorithm.
The pilot sites participated in monthly
conference calls to provide updates,
understand variance, and recommend
changes to the algorithm. Working with
the National Initiative for Children’s
Health Care Quality, the GI specialists
refined and finalized the algorithm
based on the feedback from the pilot
sites and developed a 1-page checklist
designed to guide care providers through
the algorithm.
Literature Review
To ensure that relevant evidence was not
omitted from the algorithm, an ex post
facto systematic literature review system was used to identify evidence with
regard to the treatment of constipation
in children with autism. The OVID, CINAHL,
Embase, Database of Abstracts and Review, and the Cochrane Database of
Systematic reviews databases were
searched for applicable materials. The
PEDIATRICS Volume 130, Supplement 2, November 2012
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
S99
S100
FURUTA et al
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
Intervention & Duration
Measures Used to Arrive at
Conclusion
Results
Conclusions
Pts received 1 vial of secretin at
• At baseline, completed form of sx • 11 = moderate (score 1–5). After Secretin may improve sx of
Included: 48 pts of 64 eligible
tx, 2 with moderate constipation
constipation in some children
baseline. Evaluated for 8 wk after. ranking from 0 sx absent to 12 sx
completed the study. All dx with
with ASD but evidence is limited
ceased, 2 improved, 7 did not
severe. Parents completed form
ASD or DD from a recognized
No new tx conducted in
change
to support a correlation between
concurrence.
weekly during study. Included
specialist (39 male, 9 female,
secretion and sx of constipation
bowel function: diarrhea,
ages 2–32; 5 were adults.
constipation, poor appetite,
bloating, and abdominal pain.
Control group of 5 girls and 28 boys;
• Hair analysis conducted pre and • 15 = severe constipation (6–12).
aged 2–15 y. Control group not
post for Al, As, Cd, Ca, Cu, Pb, Mg,
After tx, 5 with severe
used to compare GI sx.
Hg, K, Na.
constipation ceased, 5 improved,
and 6 had no change
• and Hg (AS 0.044 6 0.1 vs NAS
0.24 6 0.39 [P , .01])
• Pre/Post hair analysis of tx group
showed no significant difference
Bowel motions and no. of laxatives Baseline fiber 2 g/d
Fiber supplementation may
Assess dietary fiber over 3
Included: 27 severe DD children
consecutive days. Food/menu
for each child recorded
improve constipation
aged 3–17 y living in institutional
throughout study period.
in children with ASD
was managed by staff. Fiber
setting. Able to take food po and
medically stable.
supplement (wheat bran cereal
at breakfast) given over 4-mo
period in stages:
• Stage 1 (20 d): added 17 g fiber
No. of laxatives decreased
significantly from baseline and
stage 1 (1.22 6 0.36 vs 0.9 6
0.75) than to stage 2 (0.7 6
0.40). Difference in laxative
significant when comparing
baseline significant (stage 1
P , .05; stage 2 P , .01). No
significant difference between
stages 1 and 2.
• Stage 2: 10 d of normal diet
• Stage 3: 6 wk of 21 g fiber at
breakfast.
Sample
AS, autistic subjects; DD, developmental disabilities; dx, diagnosis; Lvl, level; NAS, non-autistic subjects; po, orally; pts, patients; sx, symptom; tx, treatment. Grade Categories: Category I 80% to 100% of ideal methodology met; Category II 60% to 79.99% of
ideal methodology met; Category III 40% to 59.99% of ideal methodology met; Category IV ,39.99% of ideal methodology met.
(2000)7
Pre/Post-No Control Lvl III
Tse et al
Dietary fiber intake and
constipation in children with
severe developmental
disabilities
Pre/Post-No Control Lvl III
Lonsdale et al (2000)6
A clinical study of secretin in
autism and pervasive
developmental delay
Study & Grade
TABLE 1 Systematic Literature Review Findings
SUPPLEMENT ARTICLE
FIGURE 1
Algorithm for the treatment of constipation in children. (Reprinted with permission from Constipation Guideline Committee of the North American Society for
Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American
Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1-13.)
searches were limited to primary and
secondary research conducted in humans, published in the English language,
involving children aged 0 to 18; published
between January 1995 and July 2010.
Individual studies were graded by
using an adaptation of the GRADE system5 (Table 1) by 2 primary reviewers
(K.K. and R.P.) and then reviewed by
a content expert (A.K.) for consensus.
Any discrepancies were resolved by
an unaffiliated third party.
PEDIATRICS Volume 130, Supplement 2, November 2012
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
S101
TABLE 2 Accompanying Text for the Algorithm
Box
2
2a
2b
3
4
5
2–9
8
Details
• Constipation history: frequency and consistency of stools, pain, or bleeding with passing stools; abdominal pain; waxing and waning of symptoms; age of
onset; toilet training; fecal soiling; withholding behavior; change in appetite; nausea or vomiting; weight loss; perianal fissures, dermatitis, abscess, or
fistula; current treatment, eg, current diet (24-h recall history), current medications (for all medical problems), oral, enema, suppository, herbal
• Previous treatment: diet, medications, oral, enema, suppository, herbal, previous successful treatments, behavioral treatment, results of previous tests,
estimate of parent/patient adherence
• Family history: significant illnesses; GI, eg, constipation/Hirschsprung disease; thyroid, parathyroid, cystic fibrosis, celiac disease
• Medical history: gestational age, time of passage of meconium, condition at birth, acute injury or disease, hospital admissions, immunizations, allergies,
surgeries, delayed growth and development, sensitivity to cold, coarse hair, dry skin, recurrent urinary tract infections, daytime urinary incontinence
• Developmental history: normal, delayed, school performance
• Psychosocial history: psychosocial disruption of child or family, interaction with peers, temperament, toilet habits at school
Physical examination of children with constipation:
General appearance, vital signs (temperature, pulse, respiratory rate, blood pressure, growth parameters), head, ears, eyes, nose, throat, neck,
cardiovascular, lungs and chest, abdomen (distension, palpable liver and spleen, fecal mass), anal inspection (position, stool present around anus or on
clothes, perianal erythema, skin tags, anal fissures), rectal examination (anal wink, anal tone, fecal mass, presence of stool, consistency of stool, other
masses, explosive stool on withdrawal of finger, occult blood in stool), back and spine examination (dimple, tuft of hair), neurologic examination (tone,
strength, cremasteric reflex, deep tendon reflexes)
Red flags include fever, abdominal distension, anorexia, nausea, vomiting, weight loss, or poor weight gain, which could be signs of an organic disorder. Red
flags also include symptoms indicative of needing treatment by nasogastric tube.
If red flag workup indicates treatment or referral not related to GI issues, complete this treatment or referral to appropriate specialist (eg, pediatric
gastroenterology, endocrinology). Continue to treat constipation by following algorithm steps.
Failure to thrive, abdominal distension, lack of lumbosacral curve, pilonidal dimple covered by a tuft of hair, midline pigmentary abnormalities of the lower spine,
abnormal lower extremity neurologic findings, reflexes
Fecal impaction is defined as a hard mass in the lower abdomen identified during physical examination, a dilated rectum filled with a large amount of stool found
during rectal examination, or excessive stool in the colon identified by abdominal radiography.
Disimpaction Tips
Oral and rectal treatments for disimpaction are both effective. The preferred treatment of the child should be determined through discussion with the family
and child. Because of the sensitivities to taste and/or texture often seen in individuals on the spectrum, treatments with little taste or that can be flavored to
suit the patient are preferred. Kristalose and Miralax are effective treatments and generally well accepted by this population.
When using rectal treatments, suppositories are effective and recommended, especially in low-functioning children. One of the following is recommended
when the oral route is selected: (1) use of an oral electrolyte solution with the laxatives, (2) the listed laxatives used alone, or (3) the listed laxatives be used
in combination for initial disimpaction.
Rectal disimpaction may be performed with saline enemas, or mineral oil enemas. These enemas are widely used and are effective. The use of soapsuds, tap
water, or magnesium enemas is not recommended because of their potential toxicity.
Behavior modification and establishment of regular toilet habits is a requirement for effective treatment. Toilet time scheduled 15–20 min after meals may take
advantage of the gastrocolic reflex and improve success. This can also help the patient learn to recognize normal body sensations that are associated with
need for defecation. It is also important to use appropriate reinforcers (eg, praise, stickers, preferred activities). Diaries are useful for tracking progress.
Close follow-up with the family, by phone or office visit, helps the clinician provide the family with needed encouragement and reinforcement as well as
adjustment of the treatment schedule or medications.
Maintenance Therapy
After successful treatment of impaction, and establishment of regular toilet habits, long-term maintenance is needed. This includes dietary change to ensure
appropriate fiber and fluid intake. This may require nutritional consultation and consideration of the patient’s sensitivities to various foods.
Relapse or treatment failure is most commonly associated with inadequate dosing of maintenance laxatives or premature discontinuation of treatment.
Caregivers should be informed of the need for several months of treatment.
Colonic transit time: Some patients have a history of infrequent bowel movements but have no objective findings of constipation. The history obtained from
the parents and child may not be entirely accurate. In these patients, an evaluation of colonic transit time with radiopaque markers may be helpful. The
quantification of transit time shows whether constipation is present and provides an objective evaluation of bowel movement frequency. If the transit time
is normal, the child does not have constipation. If the transit time is normal and there is no soiling, the child needs no further evaluation.
In children who have soiling without evidence of constipation, the best results have been achieved with behavior modification, but in some instances,
psychological evaluation and treatment may be necessary. If the transit study is abnormal or fecal impaction is present, further evaluation is needed.
When there is objective evidence of constipation and it is refractory to treatment, it is important to consider Hirschsprung disease.
These boxes should be repeated on provider’s clinical judgment until it is most reasonable to conduct blood tests to evaluate for other conditions.
Please see medication descriptions in Table 4.
RESULTS
Algorithm
The algorithm describes 10 steps in the
evaluation and management of constipation in children with ASD (Fig 1). A
smooth-edged box indicates a starting
S102
or ending point, a sharp-edged box
indicates a predefined process or specific action, and a diamond shape
indicates a point of decision. The items
in the accompanying text are points
of elaboration whose number corresponds to the algorithm item number
(Table 2). To facilitate practical implementation of the algorithm during the
patient–health care provider interaction,
the Constipation Checklist summarizes
key steps (Table 3) to be completed
during the visit. Children with ASD often
have unusual oral texture and/or taste
FURUTA et al
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
SUPPLEMENT ARTICLE
sensitivity. This sensitivity might adversely affect compliance with certain of the
medications used in neurotypical children, requiring health care providers to
try different medical regimens (Table 4).
Literature Review
A total of 1528 articles were located.
After removing review articles, commentaries, case studies with an n of fewer
than 10, nonintervention trials, and reports
that did not address our target questions, 2 articles remained (see Table 1).
Algorithm Testing Results and
Discussion Points
The algorithm was field tested at 4 ATN
sites (University of Arkansas for Medical Sciences and Arkansas Children’s
Hospital, Cincinnati Children’s Hospital
Medical Center, University of Colorado
Denver School of Medicine, and the
University of Rochester Medical Center).
The objective was to systematically
document the feasibility of implementing the algorithm in children with ASD
and constipation. The algorithm was
completed on a total of 48 children. At
the 4 sites, a total of 48 children completed the algorithm. Findings indicated
that each ATN site differed in practice
flow. New and previously seen patients
entered the algorithm at the beginning
when constipation was identified. For
patients who responded to impaction
treatment but were not symptom free at
the time of follow-up, treatment medications were adjusted 69% (18/26) of
the time. Long-term follow-up was arranged for 82% (28/34) of patients in
whom treatment was found to be effective. Patients were effectively managed with parental education, dietary
modification, behavioral strategies, and
oral medications 51% (22/43) of the
time. No children were referred to specialists other than pediatric gastroenterology. Additionally, the blood test step
was used in only 1 patient of the 48.
The sites reported that the final algorithm was readily applied and did not
interrupt the clinic flow of the autism
specialist. When treatment was deemed
effective, long-term follow-up was done
by either the primary care provider or
care continued to be provided by the
autism specialist.
Most patients required medication adjustments in follow-up visits, which
indicates the importance of follow-up,
particularly because pharmaceutical
and dietary management have such a
central role in the treatment of chronic
constipation. Not surprisingly, the only
referrals deemed necessary were to a
pediatric gastroenterologist.
TABLE 3 Constipation Checklist for Children with ASD
Assess
Treat
H+P include assessment for red flags
and workup if needed
(defined as fewer than 3 bowel
movements per week or
difficult defecation)
Red flags and workup if needed
Interview parents
Make a differential diagnosis
Impaction:
x-ray
abdominal
rectal
Impaction if needed
Educate family
Counsel diet (eg, increase fiber, fluid intake) and
Behavioral therapy (eg, scheduled sitting on the toilet every day)
Oral meds including PEG 3350, lactulose (note
Kristalose is clear, tasteless), Senna
Manage meds
Arrange Follow-up
Establish a consistent follow-up interval
Consider referral to pediatric gastroenterologist
Consider ordering blood test (T4, TSH, Ca, Pb, Celiac) for
children whose chronic constipation does not resolve
H+P, history and physical; meds, medications.
DISCUSSION
Clinical experience and review of the
literature indicate constipation to be a
significant problem in children with ASD;
however, data on the spectrum of clinical
manifestations, prevalence, and best
approach to evaluation and treatment
are lacking. The goal of this group, including the ATN Gastroenterology Committee, the test sites, and members
of the National Initiative for Children’s
Health Care Quality, was to develop a
practical and effective algorithm and
checklist for the evaluation and management of constipation in children with
ASD by the primary care practitioner.
Within this context, any child with ASD
and signs or symptoms (including
atypical) consistent with the possibility
of constipation should undergo an evaluation as defined in the algorithm and
with the use of the checklist. Examples
of atypical behaviors include selfabusive behavior (biting or hitting oneself, head banging) or posturing, such
as bending over furniture, grimacing,
holding the abdomen, squeezing the
legs together, walking around with a
narrow gait to hold stool in. Based on
the outcome of the initial evaluation per
the algorithm, referral to a GI specialist
may or may not be indicated. Our experience from the field-testing component of the algorithm indicated that
the algorithm is readily usable and did
not interrupt the flow of the clinic.
The fact that most children responded
to the modified algorithm suggests that
they have “functional” constipation (not
caused by an otherwise known pathologic reason) as is true in neurotypical
children. Additionally, it was evident that
most of the children, even some with
encopresis, could be managed by non-GI
specialist health care providers with the
assistance of the presented paradigm.
Regular follow-up (either by phone
or clinic visit) to document continued
response to the regimen was found
to be critical for success. Identifying
PEDIATRICS Volume 130, Supplement 2, November 2012
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
S103
TABLE 4 Constipation Algorithm Text: Medication Options
Laxatives
Osmotic
Lactulosea
Sorbitola
Magnesium hydroxidea
Magnesium citratea
Dosage
Side Effects
1–3 mL/kg/d in divided doses;
available as 70% solution.
1–3 mL/kg/d in divided doses;
available as 70% solution.
1–3 mL/kg/d of 400 mg/5 mL;
available as liquid, 400 mg/5 mL
and 800 mg/5mL, and tablets.
,6 y, 103 mL/kg/d; 6–12 y, 100–150
mL/kg/d; .12 y, 150–300 mL/kg/d;
in single or divided doses. Available
as liquid, 16.17% magnesium.
Notes
Flatulence, abdominal cramps; hypernatremia
has been reported when used in high dosage
for hepatic encephalopathy; case reports of
nontoxic megacolon in elderly.
Same as lactulose.
Infants are susceptible to magnesium
poisoning. Overdose can lead to
hypermagnesemia, hypophosphatemia,
and secondary hypocalcemia.
Infants are susceptible to magnesium
poisoning. Overdose can lead to
hypermagnesemia, hypophosphatemia,
and secondary hypocalcemia.
Osmotic enema
Lavage
Polyethylene glycolelectrolyte solution
Disimpaction: 1–1.5 g/kg/d for 3 d
Maintenance 1 g/kg/d
For disimpaction: 25 mL/kg/h
(to 1000 mL/h) by nasogastric
tube until clear or 20 mL/kg/h
for 4 h/d. For maintenance:
(older children): 5–10 mL/kg/d.
Lubricant
Mineral oil enemaa
Saline enema
Stimulants
Senna
2–6 y: 2.5 mL/d; 6–12 y: 5–15 mL/d.
Available as syrup, 8.8 mg of
sennosides/5 mL. Also available
as granules and tablets.
Bisacodyl
$ 2 y: 0.5–1.0 suppository, 1–3 tablets
per dose. Available in 5-mg tablets
and 10-mg suppositories.
Less expensive than lactulose.
Acts as an osmotic laxative. Releases
cholecystokinin, which stimulates
GI secretion and motility. Use
with caution in renal impairment.
Effective if child will accept it; many
children with ASD reject because
of the flavor.
Tasteless, or different flavors
available (“Natural Calm”).
Superior palatability and acceptable
by children.
Magnesium oxide
PEG 3350
Synthetic disaccharide.
Well-tolerated long term.
Difficult to take. Nausea, bloating, abdominal
cramps, vomiting, and anal irritation.
Aspiration, pneumonia, pulmonary edema,
Mallory-Weiss tear. Safety of long-term
maintenance not well established.
Information mostly obtained from
use for total colonic irrigation.
May require hospital admission
and nasogastric tube.
Abdominal pain, cathartic colon (possibility of
permanent gut, nerve, or muscle damage).
Idiosyncratic hepatitis, Melanosis coli,
hypertrophic osteoarthropathy,
analgesic nephropathy.
Increased intestinal motility.
Melanosis coli improves 4–12 mo
after medications discontinued.
Can be used in conjunction with
Miralax. Once withholding
behavior is overcome, Senna
should be cut back.
Abdominal pain, diarrhea, and hypokalemia,
abnormal rectal mucosa, and (rarely)
proctitis. Case reports of urolithiasis.
Reprinted with permission from Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of
constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e8.
a Adjust dosage to induce a daily bowel movement for 1 to 2 mo.
nonresponders early and changing to
an effective regimen in a timely manner
also proved to be crucial for ongoing
success.
There was, however, a definite subset of
children, particularly those on the severe end of the ASD spectrum, who
failed to respond to standard therapy.
These children with lower cognitive abilities appeared to have difficulty correctly interpreting normal physiologic
cues, such as rectal distension with
stool, but this remains to be clarified.
Some of these children displayed classic
S104
withholding behaviors, either from past
unpleasantexperiencewithdefecationor
true rectosphincteric dyssynergia from
never having learned the correct defecation dynamics of abdominal muscle
contraction and anal sphincter relaxation.
The process of developing this algorithm and checklist, as well as clinical
experience of the ATN Gastroenterology
Committee gastroenterologists, identified certain important challenges in
assessment and management of children with ASD and constipation. Often
the only presentation is a change in
baseline behavior and not the typical
straining,passing hard infrequent stools,
and soiling. Evaluation of the child with
ASD by routine abdominal and/or rectal
examination can be difficult or not possible, leading to reliance on clinical history and characteristics of the child’s
bowel pattern. Radiographic assessment
is frequently obtained to determine
whether a fecal mass in the rectum
or excessive fecal load is present. The
effectiveness of many standard medical therapies for constipation might be
FURUTA et al
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
SUPPLEMENT ARTICLE
severely constrained because of the
volume, texture, or taste sensitivities in
children with ASD. The available literature is small, and only 2 articles even
reached the level to address the target concerns, indicating the need for
high-quality research in this field. As
a result, the health care provider, with
input from parents, may need to be
creative and try various therapeutic
agents with the aim of identifying one
to which the child will comply. There
was consensus opinion that the child
with ASD and constipation should initially undergo evaluation and management as per the algorithm presented.
Those who do not respond to this should
then be referred to a gastroenterologist.
CONCLUSIONS
As the literature on evaluation and
management of constipation in children with ASD is quite scant, development of the algorithm was
based largely on modification of the
NASPGHAN Guidelines and expert opinion and further complemented by input
after field testing. Until such time as
evidence becomes available to further
define the best approach, we recommend that the current algorithm with
accompanying text and, as a practical,
clinic-based tool, the checklist be incorporated into routine care of children
with ASD and constipation.
ACKNOWLEDGMENTS
Special thanks to the National Initiative on
Children’s Healthcare Quality for their
guidance on the algorithm creation and
testing. Review and comment on this clinical algorithm was provided by the following organizational liaisons: Paul Carbone,
MD (American Association of Pediatrics
Council on Children with Disabilities, Autism Sub-Committee); Ivor Hill, MD (American Association of Pediatrics Section on
GI and Nutrition); George Fuchs, MD
(NASPGHAN); Robin Hansen, MD (Society
for Developmental and Behavioral Pediatrics). The valuable assistance of the members of the Autism Treatment Network
Gastroenterology Committee in reviewing
this document is gratefully acknowledged.
3. Buie T, Fuchs GJ III, Furuta GT, et al. Recommendations for evaluation and treatment of
common gastrointestinal problems in children with ASDs. Pediatrics. 2010;125(suppl
1):S19–S29
4. Constipation Guideline Committee of the
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.
Evaluation and treatment of constipation in
infants and children: recommendations of
the North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition.
J Pediatr Gastroenterol Nutr. 2006;43(3):
e1–e13
5. Guyatt GH, Oxman AD, Kunz R, et al; GRADE
Working Group. Going from evidence to recommendations. BMJ. 2008;336(7652):1049–1051
6. Lonsdale D, Shamberger RJ. A clinical study of
secretin in autism and pervasive developmental
delay. J Nutr Environ Med. 2000;10(4):271–280
7. Tse PW, Leung SS, Chan T, Sien A, Chan AK.
Dietary fibre intake and constipation in children with severe developmental disabilities.
J Paediatr Child Health. 2000;36(3):236–239
REFERENCES
1. Autism and Developmental Disabilities Monitoring Network Surveillance Year 2006 Principal Investigators; Centers for Disease Control
and Prevention (CDC). Prevalence of autism
spectrum disorders - autism and developmental disabilities monitoring network, United
States, 2006. MMWR Surveill Summ. 2009;58
(10):1–20
2. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders,
Revised 4th Ed. Washington, DC: American
Psychiatric Association; 2000
PEDIATRICS Volume 130, Supplement 2, November 2012
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
S105
Management of Constipation in Children and Adolescents With Autism
Spectrum Disorders
Glenn T. Furuta, Kent Williams, Koorosh Kooros, Ajay Kaul, Rebecca Panzer, Daniel
L. Coury and George Fuchs
Pediatrics 2012;130;S98
DOI: 10.1542/peds.2012-0900H
Updated Information &
Services
including high resolution figures, can be found at:
http://pediatrics.aappublications.org/content/130/Supplement
_2/S98.full.html
References
This article cites 6 articles, 2 of which can be accessed free
at:
http://pediatrics.aappublications.org/content/130/Supplement
_2/S98.full.html#ref-list-1
Citations
This article has been cited by 3 HighWire-hosted articles:
http://pediatrics.aappublications.org/content/130/Supplement
_2/S98.full.html#related-urls
Subspecialty Collections
This article, along with others on similar topics, appears in
the following collection(s):
Development/Behavioral Issues
http://pediatrics.aappublications.org/cgi/collection/developme
nt:behavioral_issues_sub
Autism/ASD
http://pediatrics.aappublications.org/cgi/collection/autism:asd
_sub
Permissions & Licensing
Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xh
tml
Reprints
Information about ordering reprints can be found online:
http://pediatrics.aappublications.org/site/misc/reprints.xhtml
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014